STANFORD, Calif. -- A low-cost empowerment program for adolescent girls in Kenyan slums sharply curtails rape and sexual harassment of these girls, who live in an environment where women have low status and are frequently attacked, a large new study shows.

The findings, by researchers at the Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford and the nongovernmental organization Ujamaa-Africa/No Means No Worldwide, validated the program's effectiveness in combating an appallingly common hazard among girls living in the slums of Nairobi: rape. The researchers found that nearly 18 percent of participants had been raped in the year before their program began.

"This study in very poor neighborhoods in Africa demonstrated that there is a very high baseline rate of gender-based violence, but a simple intervention empowers girls to take responsibility for protecting themselves, and this leads to a major decrease in violence against those girls," said Yvonne Maldonado, MD, the senior author of the study, which will be published April 13 in Pediatrics. Maldonado is professor of pediatrics at Stanford and chief of pediatric infectious diseases at the children's hospital.

The intervention involves teaching girls verbal and physical techniques to prevent sexual harassment and assault. The study, which evaluated the effectiveness of these techniques for 1,978 adolescents living in Nairobi slums, confirms the success of a smaller pilot study of the same program that Stanford and No Means No Worldwide published last year.

In the new study, more than half of the girls in the intervention group used what they had learned in their training to fend off rape or stop sexual harassment, halting 817 assaults and 957 harassment situations in the 10.5-month study period. The rate of rape dropped from 17.9 per 100 person-years to 11.1 per 100 person-years in the girls who received training. (The rate was measured in person-years to account for the fact that questionnaires given to the girls before and after training asked about different lengths of time: The one used to document the girls' experience before training asked about the prior 12 months, while the follow-up questionnaire asked about the 10.5-month period since the girls had begun participating in training.) The results demonstrate that the program is both effective and scalable to large populations, the study's authors said.

"We're teaching girls that it is OK to say no without feeling guilty, teaching them that 'I have permission to defend myself,'" said Lee Paiva, a co-author of the study and co-founder of No Means No Worldwide, who helped develop the empowerment curriculum. As in many cultures, the topics of rape and sexual assault are usually treated with silence and shame in the girls' communities, she said. "We're countering that intense socialization that all of us go through as women."

No Means No Worldwide is studying empowerment training for girls in the context of its larger efforts to stop gender-based violence in Africa and around the globe. The organization has also developed a program for boys called Your Moment of Truth, which aims to change negative gender stereotypes that have been identified as a leading cause of violence against women. In addition, they teach the defense techniques to Kenyan grandmothers, another population vulnerable to sexual assault.

"This is the first time anyone's proven they could decrease the incidence of rape with a low-cost, simple intervention," said Jake Sinclair, MD, who co-founded No Means No Worldwide with Paiva, his wife. Sinclair is a pediatrician at John Muir Medical Center in Walnut Creek, Calif.

The subjects of the current study were 2,406 high school girls, ages 13 to 20, attending schools in impoverished Nairobi slums: 1,978 received 12 hours of empowerment training over six weeks, as well as two-hour refresher courses at three-, six- and 10-month intervals; 428 in a comparison group received a 90-minute life-skills class that is the current national standard in Kenya. The empowerment training included lessons on self-efficacy, boundaries and personal awareness; assertive communication skills; de-escalation and negotiation; and a variety of physical skills for defending against and escaping from single or multiple attackers. Before and 10.5 months after the training began, both groups answered anonymous questionnaires about their recent experiences of rape and sexual harassment.

At the start of the study, nearly one in five girls from the intervention group reported that they had been forced to have sex in the prior year. By the end of the 10.5-month study, the rate had dropped by more than a third.

Among those who received training, 52.3 percent fended off rape in the subsequent 10.5 months. Of these girls, 45 percent used verbal skills alone, 30 percent started with verbal skills and added physical skills, and 25 percent used physical skills alone. In addition, 65 percent of the girls who received training defended themselves against sexual harassment, defined as "unwanted comments, whistles or gestures with a sexual intent" and/or "unwanted sexual touching." To stop harassment, 59 percent used verbal skills only, 26 percent used verbal and physical skills and 15 percent used physical skills alone.

Girls who received training were also much more likely to disclose an assault, thus providing a crucial window for access to services to treat sexually transmitted diseases, deal with pregnancies resulting from rape, and get help for other physical or psychological aftereffects.

Among the girls who only had life-skills classes, the proportion who became victims of rape and harassment remained the same, and they were no more likely to seek help after an attack.

"Clearly, girls should never be placed in these situations in the first place," said Clea Sarnquist, DrPH, the study's lead author and a senior research scholar in pediatrics at Stanford. Changing males' attitudes and behavior about assault is an important area for the team's current and future work, she said. "But with such a high prevalence of rape, these girls need something to protect them now. By giving them the tools to speak up and the knowledge that 'I have domain over my own body,' we're giving them the opportunity to protect themselves."

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The other Stanford co-author of the study was David Cornfield, MD, professor of pediatric pulmonary medicine at Stanford and chief of pulmonary and critical care medicine at Lucile Packard Children's Hospital Stanford. Researchers from United States International University in Nairobi and from the Nairobi-based nongovernmental organization UJAMAA Africa also worked on the study.

The study was funded by Manasseh's Children, a U.S.-based nongovernmental organization.

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